For patients with Stage IIIB or IV HD flowing Bv-AVEPC with initial large mediastinal adenopathy, how can we avoid ISRT?

It is true that on the clinical trial AHOD1331, patients who presented with large mediastinal adenopathy received radiation therapy as did patients who were slow early responders (Deauville 4 or 5 after two cycles of therapy). It is noteworthy that 3-year event-free survival was extremely high for all patients except those with stage IVB at presentation. This tells us that we are likely overtreating many of the high-risk patients and if we were designing a follow-up clinical trial using the Bv-A...

Excellent question.

Dr. @Dr. First Last's answer above is informative particularly the remarkable rates of radiation with N-AVD of 0.4%, while maintaining excellent outcomes. That is a preferred approach compared to what I will say next.

The only addition I have: I had a patient with stage IIB with bulk (not included in the S1826 trial population) that I used the HLHR13 instead of ABVE-PC in order to give her a chance of avoiding radiation. The St. Jude's HLHR13 protocol used AEPA-CAPDac (based o...